January case teaser: persistent diarrhea in an ICU patient

A 42 year old male was admitted to the ICU following a motor vehicle collision (MVC). The patient currently has a diverting ileostomy, after losing most of the colon to ischemia secondary to blunt trauma to his abdomen during the MVC. The patient developed ventilator-associated pneumonia (VAP) several days after the operation to remove a significant amount of ischemic colon and construct the ileostomy; he was treated with seven-day course of broad-spectrum antibiotics for the VAP.

After completing antibiotic therapy for the pneumonia, the patient developed diarrhea with high volume output from the ileostomy; despite consultation with the nutritionist and numerous interventions (e.g. administration of antidiarrheal agents) over the course of several days, the patient continues to have significant output from his ileostomy.

During morning rounds, one of the residents mentions that the team had sent a sample of the ileostomy output to be tested for Clostridium difficile. The team discusses the Clostridium difficile organism as one of the most common causes of diarrhea in the ICU, particularly in patients with a recent history of exposure toantibiotics. However, C. difficile typically involves the colon rather than the small intestine, and the current patient has loss of continuity between the small intestine and colon because of the ileostomy.

The attending physician notes that he has not heard of C. difficile infection involving the small intestine and asks you, as the team’s evidence consultant, to explore whether the literature indicates that the small intestine can be involved in C. difficile infection and if such infection can develop despite loss of continuity with the colon (due to the presence of the ileostomy in this patient).

We'll post a link to the online case as soon as it is available via PubMed Central.